§ 1396a. State plans for medical assistance

Guidance on Access to Medicaid for Former Foster Youth

Pub. L. 115–271, title I, § 1002(b), Oct. 24, 2018, 132 Stat. 3902, provided that: “Not later than 1 year after the date of the enactment of this Act [Oct. 24, 2018], the Secretary of Health and Human Services shall issue guidance to States, with respect to the State Medicaid programs of such States— “(1) on best practices for—“(A) removing barriers and ensuring streamlined, timely access to Medicaid coverage for former foster youth up to age 26; and “(B) conducting outreach and raising awareness among such youth regarding Medicaid coverage options for such youth; and “(2) which shall include examples of States that have successfully extended Medicaid coverage to former foster youth up to age 26.”

Guidance To Improve Care for Infants With Neonatal Abstinence Syndrome and Their Mothers

Pub. L. 115–271, title I, § 1005(a), Oct. 24, 2018, 132 Stat. 3912, provided that: “Not later than 1 year after the date of the enactment of this Act [Oct. 24, 2018], the Secretary of Health and Human Services shall issue guidance to improve care for infants with neonatal abstinence syndrome and their families. Such guidance shall include— “(1) best practices from States with respect to innovative or evidenced-based payment models that focus on prevention, screening, treatment, plans of safe care, and postdischarge services for mothers and fathers with substance use disorders and babies with neonatal abstinence syndrome that improve care and clinical outcomes; “(2) recommendations for States on available financing options under the Medicaid program under title XIX of such Act [probably means title XIX of the Social Security Act, 42 U.S.C. 1396 et seq.] and under the Children’s Health Insurance Program under title XXI of such Act [probably means title XXI of the Social Security Act, 42 U.S.C. 1397aa et seq.] for Children’s Health Insurance Program Health Services Initiative funds for parents with substance use disorders, infants with neonatal abstinence syndrome, and home-visiting services; “(3) guidance and technical assistance to State Medicaid agencies regarding additional flexibilities and incentives related to screening, prevention, and postdischarge services, including parenting supports, and infant-caregiver bonding, including breastfeeding when it is appropriate; and “(4) guidance regarding suggested terminology and ICD codes to identify infants with neonatal abstinence syndrome and neonatal opioid withdrawal syndrome, which could include opioid-exposure, opioid withdrawal not requiring pharmacotherapy, and opioid withdrawal requiring pharmacotherapy.”

Medicaid Substance Use Disorder Treatment via Telehealth

Pub. L. 115–271, title I, § 1009(a), (b), Oct. 24, 2018, 132 Stat. 3917, provided that: “(a) Definitions.—In this section:“(1) Comptroller general.—The term ‘Comptroller General’ means the Comptroller General of the United States. “(2) School-based health center.—The term ‘school-based health center’ has the meaning given that term in section 2110(c)(9) of the Social Security Act (42 U.S.C. 1397jj(c)(9)). “(3) Secretary.—The term ‘Secretary’ means the Secretary of Health and Human Services. “(4) Underserved area.—The term ‘underserved area’ means a health professional shortage area (as defined in section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A))) and a medically underserved area (according to a designation under section 330(b)(3)(A) of the Public Health Service Act (42 U.S.C. 254b(b)(3)(A))). “(b) Guidance to States Regarding Federal Reimbursement for Furnishing Services and Treatment for Substance Use Disorders Under Medicaid Using Services Delivered Via Telehealth, Including in School-Based Health Centers.—Not later than 1 year after the date of enactment of this Act [Oct. 24, 2018], the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall issue guidance to States on the following:“(1) State options for Federal reimbursement of expenditures under Medicaid for furnishing services and treatment for substance use disorders, including assessment, medication-assisted treatment, counseling, medication management, and medication adherence with prescribed medication regimes, using services delivered via telehealth. Such guidance shall also include guidance on furnishing services and treatments that address the needs of high-risk individuals, including at least the following groups:“(A) American Indians and Alaska Natives. “(B) Adults under the age of 40. “(C) Individuals with a history of non-fatal overdose. “(D) Individuals with a co-occurring serious mental illness and substance use disorder. “(2) State options for Federal reimbursement of expenditures under Medicaid for education directed to providers serving Medicaid beneficiaries with substance use disorders using the hub and spoke model, through contracts with managed care entities, through administrative claiming for disease management activities, and under Delivery System Reform Incentive Payment (‘DSRIP’) programs. “(3) State options for Federal reimbursement of expenditures under Medicaid for furnishing services and treatment for substance use disorders for individuals enrolled in Medicaid in a school-based health center using services delivered via telehealth.”

Enhancing Patient Access to Non-Opioid Treatment Options

Pub. L. 115–271, title I, § 1010, Oct. 24, 2018, 132 Stat. 3918, provided that: “Not later than January 1, 2019, the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall issue 1 or more final guidance documents, or update existing guidance documents, to States regarding mandatory and optional items and services that may be provided under a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or under a waiver of such a plan, for non-opioid treatment and management of pain, including, but not limited to, evidence-based, non-opioid pharmacological therapies and non-pharmacological therapies.”

Technical Assistance and Support for Innovative State Strategies To Provide Housing-Related Supports Under Medicaid

Pub. L. 115–271, title I, § 1018, Oct. 24, 2018, 132 Stat. 3924, provided that: “(a) In General.—The Secretary of Health and Human Services shall provide technical assistance and support to States regarding the development and expansion of innovative State strategies (including through State Medicaid demonstration projects) to provide housing-related supports and services and care coordination services under Medicaid to individuals with substance use disorders. “(b) Report.—Not later than 180 days after the date of enactment of this Act [Oct. 24, 2018], the Secretary shall issue a report to Congress detailing a plan of action to carry out the requirements of subsection (a).”

Medicaid Reentry

Pub. L. 115–271, title V, subtitle D, Oct. 24, 2018, 132 Stat. 3965, provided that: “SEC. 5031. SHORT TITLE.“This subtitle may be cited as the ‘Medicaid Reentry Act’. “SEC. 5032. PROMOTING STATE INNOVATIONS TO EASE TRANSITIONS INTEGRATION TO THE COMMUNITY FOR CERTAIN INDIVIDUALS.“(a) Stakeholder Group Development of Best Practices; State Medicaid Program Innovation.—“(1) Stakeholder group best practices.—Not later than 6 months after the date of the enactment of this Act [Oct. 24, 2018], the Secretary of Health and Human Services shall convene a stakeholder group of representatives of managed care organizations, Medicaid beneficiaries, health care providers, the National Association of Medicaid Directors, and other relevant representatives from local, State, and Federal jail and prison systems to develop best practices (and submit to the Secretary and Congress a report on such best practices) for States—“(A) to ease the health care-related transition of an individual who is an inmate of a public institution from the public institution to the community, including best practices for ensuring continuity of health insurance coverage or coverage under the State Medicaid plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], as applicable, and relevant social services; and “(B) to carry out, with respect to such an individual, such health care-related transition not later than 30 days after such individual is released from the public institution. “(2) State medicaid program innovation.—The Secretary of Health and Human Services shall work with States on innovative strategies to help individuals who are inmates of public institutions and otherwise eligible for medical assistance under the Medicaid program under title XIX of the Social Security Act transition, with respect to enrollment for medical assistance under such program, seamlessly to the community. “(b) Guidance on Innovative Service Delivery Systems Demonstration Project Opportunities.—Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services, through the Administrator of the Centers for Medicare & Medicaid Services, shall issue a State Medicaid Director letter, based on best practices developed under subsection (a)(1), regarding opportunities to design demonstration projects under section 1115 of the Social Security Act (42 U.S.C. 1315) to improve care transitions for certain individuals who are soon-to-be former inmates of a public institution and who are otherwise eligible to receive medical assistance under title XIX of such Act, including systems for, with respect to a period (not to exceed 30 days) immediately prior to the day on which such individuals are expected to be released from such institution—“(1) providing assistance and education for enrollment under a State plan under the Medicaid program under title XIX of such Act for such individuals during such period; and “(2) providing health care services for such individuals during such period. “(c) Rule of Construction.—Nothing under title XIX of the Social Security Act or any other provision of law precludes a State from reclassifying or suspending (rather than terminating) eligibility of an individual for medical assistance under title XIX of the Social Security Act while such individual is an inmate of a public institution.”

Development of Uniform Terminology for Reasons for Provider Termination

Pub. L. 114–255, div. A, title V, § 5005(a)(5), Dec. 13, 2016, 130 Stat. 1193, provided that: “Not later than July 1, 2017, the Secretary of Health and Human Services shall, in consultation with the heads of State agencies administering State Medicaid plans (or waivers of such plans), issue regulations establishing uniform terminology to be used with respect to specifying reasons under subparagraph (A)(v) of paragraph (8) of section 1902(kk) of the Social Security Act (42 U.S.C. 1396a(kk)), as added by paragraph (1), for the termination (as described in such paragraph (8)) of the participation of certain providers in the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.] or the Children’s Health Insurance Program under title XXI of such Act [42 U.S.C. 1397aa et seq.].”

Exception for State Legislation

Pub. L. 114–255, div. A, title V, § 5006(d), Dec. 13, 2016, 130 Stat. 1196, provided that: “In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), which the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet one or more additional requirements imposed by amendments made by this section [amending this section], the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act [Dec. 13, 2016]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature.”

Rule of Construction Related to Medicaid Coverage of Mental Health Services and Primary Care Services Furnished on the Same Day

Pub. L. 114–255, div. B, title XII, § 12001, Dec. 13, 2016, 130 Stat. 1272, provided that: “Nothing in title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) shall be construed as prohibiting separate payment under the State plan under such title (or under a waiver of the plan) for the provision of a mental health service or primary care service under such plan, with respect to an individual, because such service is— “(1) a primary care service furnished to the individual by a provider at a facility on the same day a mental health service is furnished to such individual by such provider (or another provider) at the facility; or “(2) a mental health service furnished to the individual by a provider at a facility on the same day a primary care service is furnished to such individual by such provider (or another provider) at the facility.”

Demonstration Programs To Improve Community Mental Health Services

Pub. L. 113–93, title II, § 223, Apr. 1, 2014, 128 Stat. 1077, as amended by Pub. L. 116–16, § 4, Apr. 18, 2019, 133 Stat. 859; Pub. L. 116–29, § 1, July 5, 2019, 133 Stat. 1031; Pub. L. 116–39, § 2, Aug. 6, 2019, 133 Stat. 1061; Pub. L. 116–59, div. B, title III, § 1301, Sept. 27, 2019, 133 Stat. 1105; Pub. L. 116–69, div. B, title III, § 1301, Nov. 21, 2019, 133 Stat. 1137; Pub. L. 116–94, div. N, title I, § 201, Dec. 20, 2019, 133 Stat. 3103; Pub. L. 116–136, div. A, title III, § 3814(a), (b), Mar. 27, 2020, 134 Stat. 430, 431; Pub. L. 116–159, div. C, title III, § 2304, Oct. 1, 2020, 134 Stat. 732; Pub. L. 116–215, div. B, title I, § 1104, Dec. 11, 2020, 134 Stat. 1043; Pub. L. 116–260, div. CC, title II, § 206, Dec. 27, 2020, 134 Stat. 2984; Pub. L. 117–159, div. A, title I, § 11001, June 25, 2022, 136 Stat. 1314, provided that: “(a) Criteria for Certified Community Behavioral Health Clinics To Participate in Demonstration Programs.—“(1) Publication.—Not later than September 1, 2015, the Secretary shall publish criteria for a clinic to be certified by a State as a certified community behavioral health clinic for purposes of participating in a demonstration program conducted under subsection (d). “(2) Requirements.—The criteria published under this subsection shall include criteria with respect to the following:“(A) Staffing.—Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State-required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic’s patient population. “(B) Availability and accessibility of services.—Availability and accessibility of services, including crisis management services that are available and accessible 24 hours a day, the use of a sliding scale for payment, and no rejection for services or limiting of services on the basis of a patient’s ability to pay or a place of residence. “(C) Care coordination.—Care coordination, including requirements to coordinate care across settings and providers to ensure seamless transitions for patients across the full spectrum of health services including acute, chronic, and behavioral health needs. Care coordination requirements shall include partnerships or formal contracts with the following:“(i) Federally-qualified health centers (and as applicable, rural health clinics) to provide Federally-qualified health center services (and as applicable, rural health clinic services) to the extent such services are not provided directly through the certified community behavioral health clinic. “(ii) Inpatient psychiatric facilities and substance use detoxification, post-detoxification step-down services, and residential programs. “(iii) Other community or regional services, supports, and providers, including schools, child welfare agencies, juvenile and criminal justice agencies and facilities, Indian Health Service youth regional treatment centers, State licensed and nationally accredited child placing agencies for therapeutic foster care service, and other social and human services. “(iv) Department of Veterans Affairs medical centers, independent outpatient clinics, drop-in centers, and other facilities of the Department as defined in section 1801 [probably should be 1701] of title 38, United States Code. “(v) Inpatient acute care hospitals and hospital outpatient clinics. “(D) Scope of services.—Provision (in a manner reflecting person-centered care) of the following services which, if not available directly through the certified community behavioral health clinic, are provided or referred through formal relationships with other providers:“(i) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization. “(ii) Screening, assessment, and diagnosis, including risk assessment. “(iii) Patient-centered treatment planning or similar processes, including risk assessment and crisis planning. “(iv) Outpatient mental health and substance use services. “(v) Outpatient clinic primary care screening and monitoring of key health indicators and health risk. “(vi) Targeted case management. “(vii) Psychiatric rehabilitation services. “(viii) Peer support and counselor services and family supports. “(ix) Intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas, provided the care is consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration. “(E) Quality and other reporting.—Reporting of encounter data, clinical outcomes data, quality data, and such other data as the Secretary requires. “(F) Organizational authority.—Criteria that a clinic be a non-profit or part of a local government behavioral health authority or operated under the authority of the Indian Health Service, an Indian tribe or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 [450f] et seq.) [now 25 U.S.C. 5321 et seq.], or an urban Indian organization pursuant to a grant or contract with the Indian Health Service under title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 [1651] et seq.). “(b) Guidance on Development of Prospective Payment System for Testing Under Demonstration Programs.—“(1) In general.—Not later than September 1, 2015, the Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, shall issue guidance for the establishment of a prospective payment system that shall only apply to medical assistance for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program under subsection (d). “(2) Requirements.—The guidance issued by the Secretary under paragraph (1) shall provide that—“(A) no payment shall be made for inpatient care, residential treatment, room and board expenses, or any other non-ambulatory services, as determined by the Secretary; and “(B) no payment shall be made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this Act [Apr. 1, 2014]. “(c) Planning Grants.—“(1) In general.—Not later than January 1, 2016, the Secretary shall award planning grants to States for the purpose of developing proposals to participate in time-limited demonstration programs described in subsection (d). “(2) Use of funds.—A State awarded a planning grant under this subsection shall—“(A) solicit input with respect to the development of such a demonstration program from patients, providers, and other stakeholders; “(B) certify clinics as certified community behavioral health clinics for purposes of participating in a demonstration program conducted under subsection (d); and “(C) establish a prospective payment system for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program under subsection (d) in accordance with the guidance issued under subsection (b). “(3) Additional planning grants for states.—In addition to the planning grants awarded under paragraph (1), as soon as practicable after the date of enactment of this paragraph [June 25, 2022], the Secretary shall award planning grants to States (other than States selected to conduct demonstration programs under paragraph (1) or (8) of subsection (d)) to develop proposals to participate in time-limited demonstration programs described in subsection (d) so that, beginning July 1, 2024, and every 2 years thereafter, up to 10 additional States may participate in the demonstration programs described in subsection (d) in accordance with paragraph (9) of that subsection. “(d) Demonstration Programs.—“(1) In general.—Not later than September 1, 2017, the Secretary shall select States to participate in demonstration programs that are developed through planning grants awarded under subsection (c), meet the requirements of this subsection, and represent a diverse selection of geographic areas, including rural and underserved areas. “(2) Application requirements.—“(A) In general.—The Secretary shall solicit applications to participate in demonstration programs under this subsection solely from States awarded planning grants under subsection (c). “(B) Required information.—An application for a demonstration program under this subsection shall include the following:“(i) The target Medicaid population to be served under the demonstration program. “(ii) A list of participating certified community behavioral health clinics. “(iii) Verification that the State has certified a participating clinic as a certified community behavioral health clinic in accordance with the requirements of subsection (b). “(iv) A description of the scope of the mental health services available under the State Medicaid program that will be paid for under the prospective payment system tested in the demonstration program. “(v) Verification that the State has agreed to pay for such services at the rate established under the prospective payment system. “(vi) Such other information as the Secretary may require relating to the demonstration program including with respect to determining the soundness of the proposed prospective payment system. “(3) Number and length of demonstration programs.—Subject to paragraphs (8) and (9), not more than 8 States shall be selected to conduct demonstration programs that meet the requirements of this subsection through September 30, 2025. “(4) Requirements for selecting demonstration programs.—“(A) In general.—The Secretary shall give preference to selecting demonstration programs where participating certified community behavioral health clinics—“(i) provide the most complete scope of services described in subsection (a)(2)(D) to individuals eligible for medical assistance under the State Medicaid program; “(ii) will improve availability of, access to, and participation in, services described in subsection (a)(2)(D) to individuals eligible for medical assistance under the State Medicaid program; “(iii) will improve availability of, access to, and participation in assisted outpatient mental health treatment in the State; or “(iv) demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net Federal spending. “(5) Payment for medical assistance for mental health services provided by certified community behavioral health clinics.—“(A) In general.—The Secretary shall pay a State participating in a demonstration program under this subsection the Federal matching percentage specified in subparagraph (B) for amounts expended by the State to provide medical assistance for mental health services described in the demonstration program application in accordance with paragraph (2)(B)(iv) that are provided by certified community behavioral health clinics to individuals who are enrolled in the State Medicaid program. Payments to States made under this paragraph shall be considered to have been under, and are subject to the requirements of, section 1903 of the Social Security Act (42 U.S.C. 1396b). “(B) Federal matching percentage.—Subject to subparagraph (C)(iii), the Federal matching percentage specified in this subparagraph is with respect to medical assistance described in subparagraph (A) that is furnished by a State participating in an ongoing demonstration program under this subsection—“(i) to a newly eligible individual described in paragraph (2) of section 1905(y) of the Social Security Act (42 U.S.C. 1396d(y)), the matching rate applicable under paragraph (1) of that section; and “(ii) to an individual who is not a newly eligible individual (as so described) but who is eligible for medical assistance under the State Medicaid program, the enhanced FMAP applicable to the State. “(C) Limitations.—“(i) In general.—Payments shall be made under this paragraph to a State only for mental health services— “(I) that are described in the demonstration program application in accordance with paragraph (2)(iv); “(II) for which payment is available under the State Medicaid program; and “(III) that are provided to an individual who is eligible for medical assistance under the State Medicaid program. “(ii) Prohibited payments.—No payment shall be made under this paragraph— “(I) for inpatient care, residential treatment, room and board expenses, or any other non-ambulatory services, as determined by the Secretary; or “(II) with respect to payments made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this Act [Apr. 1, 2014]. “(iii) Payments for amounts expended after 2019.—The Federal matching percentage applicable under subparagraph (B) to amounts expended by a State participating in the demonstration program under this subsection shall— “(I) in the case of a State participating in the demonstration program as of January 1, 2020, apply to amounts expended by the State through September 30, 2025; “(II) in the case of a State selected to participate in the demonstration program under paragraph (8), during the first 24 fiscal quarter period (or any portion of such period) that the State participates in the demonstration program; and “(III) in the case of a State selected to participate in the demonstration program under paragraph (9), during the first 16 fiscal quarter period (or any portion of such period) that the State participates in the demonstration program. “(D) Rule of construction.—Nothing in this section shall be construed as prohibiting a State that participated in a demonstration program under this subsection that has ended from receiving Federal financial participation under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for amounts expended by the State under a State plan under such title (or a waiver of such plan) for providing medical assistance for items and services, and carrying out activities, including continuing to pay for services under the prospective payment system established under subsection (c), that were provided or carried out by the State under the demonstration program, to the extent such financial participation is otherwise available under such title. “(6) Waiver of statewideness requirement.—The Secretary shall waive section 1902(a)(1) of the Social Security Act (42 U.S.C. 1396a(a)(1)) (relating to statewideness) as may be necessary to conduct demonstration programs in accordance with the requirements of this subsection. “(7) Annual reports.—“(A) In general.—Not later than 1 year after the date on which the first State is selected for a demonstration program under this subsection, and annually thereafter through the year in which the last demonstration under this section ends, the Secretary shall submit to Congress an annual report on the use of funds provided under all demonstration programs conducted under this subsection. Each such report shall include—“(i) an assessment of access to community-based mental health services under the Medicaid program in the area or areas of a State targeted by a demonstration program compared to other areas of the State; “(ii) an assessment of the quality and scope of services provided by certified community behavioral health clinics compared to community-based mental health services provided in States not participating in a demonstration program under this subsection and in areas of a demonstration State that are not participating in the demonstration program; and “(iii) an assessment of the impact of the demonstration programs on the Federal and State costs of a full range of mental health services (including inpatient, emergency and ambulatory services). “(B) Recommendations.—Not later than September 30, 2025, the Secretary shall submit to Congress recommendations concerning whether the demonstration programs under this section should be continued, expanded, modified, or terminated. Such recommendations shall include data collected after 2019, where feasible. “(C) Final evaluation.—Not later than 24 months after all demonstration programs under this section have ended, the Secretary shall submit to Congress a final evaluation of such programs. “(8) Additional programs.—“(A) In general.—Not later than 6 months after the date of enactment of this paragraph [Mar. 27, 2020], in addition to the 8 States selected under paragraph (1), the Secretary shall select 2 States to conduct demonstration programs that meet the requirements of this subsection for 6 years. “(B) Selection of states.—“(i) In general.—Subject to clause (ii), in selecting States under this paragraph, the Secretary— “(I) shall select States that—“(aa) were awarded planning grants under subsection (c); and “(bb) applied to participate in the demonstration programs under this subsection under paragraph (1) but, as of the date of enactment of this paragraph, were not selected to participate under paragraph (1); and “(II) shall use the results of the Secretary’s evaluation of each State’s application under paragraph (1) to determine which States to select, and shall not require the submission of any additional application. “(C) Requirements for selected states.—Prior to services being delivered under the demonstration authority in a State selected under this paragraph, the State shall—“(i) submit a plan to monitor certified community behavioral health clinics under the demonstration program to ensure compliance with certified community behavioral health criteria during the demonstration period; and “(ii) commit to collecting data, notifying the Secretary of any planned changes that would deviate from the prospective payment system methodology outlined in the State’s demonstration application, and obtaining approval from the Secretary for any such change before implementing the change. “(9) Further additional programs.—“(A) In general.—In addition to the States selected under paragraphs (1) and (8), the Secretary shall select any State that meets the requirements described in subparagraph (B) to conduct a demonstration program that meets the requirements of this subsection for 4 years. “(B) Requirements.—The requirements described in this subparagraph with respect to a State are that the State—“(i) was awarded a planning grant under paragraph (1) or (3) of subsection (c); and “(ii) submits an application (in addition to any application that the State may have previously submitted under this section) that includes the information described in paragraph (2)(B). “(C) Requirements for selected states.—The requirements applicable to States selected under paragraph (8) pursuant to subparagraph (C) of such paragraph shall apply in the same manner to States selected under this paragraph. “(D) Limitation.—The Secretary shall not select more than 10 States to conduct a demonstration program under this paragraph for each 2 fiscal year period. “(e) Definitions.—In this section:“(1) Federally-qualified health center services; federally-qualified health center; rural health clinic services; rural health clinic.—The terms ‘Federally-qualified health center services’, ‘Federally-qualified health center’, ‘rural health clinic services’, and ‘rural health clinic’ have the meanings given those terms in section 1905(l) of the Social Security Act (42 U.S.C. 1396d(l)). “(2) Enhanced fmap.—The term ‘enhanced FMAP’ has the meaning given that term in section 2105(b) of the Social Security Act (42 U.S.C. 1397dd(b) [1397ee(b)]) but without regard to the second and third sentences of that section. “(3) Secretary.—The term ‘Secretary’ means the Secretary of Health and Human Services. “(4) State.—The term ‘State’ has the meaning given such term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). “(f) Funding.—“(1) In general.—Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary—“(A) for purposes of carrying out subsections (a), (b), and (d)(7), $2,000,000 for fiscal year 2014; “(B) for purposes of awarding planning grants under subsection (c), $25,000,000 for fiscal year 2016; and “(C) for purposes of awarding planning grants under subsection (c)(3), providing technical assistance to States applying for grants under such subsection, and carrying out demonstration programs under subsection (d), $40,000,000 for fiscal year 2023, to remain available until expended. “(2) Availability.—Funds appropriated under paragraph (1) shall remain available until expended.”

Reports to Congress

Pub. L. 111–148, title II, § 2001(d)(2), Mar. 23, 2010, 124 Stat. 278, provided that: “Beginning April 2015, and annually thereafter, the Secretary of Health and Human Services shall submit a report to the appropriate committees of Congress on the total enrollment and new enrollment in Medicaid for the fiscal year ending on September 30 of the preceding calendar year on a national and State-by-State basis, and shall include in each such report such recommendations for administrative or legislative changes to improve enrollment in the Medicaid program as the Secretary determines appropriate.”

Demonstration Project To Evaluate Integrated Care Around a Hospitalization

Pub. L. 111–148, title II, § 2704, Mar. 23, 2010, 124 Stat. 323, provided that: “(a) Authority To Conduct Project.—“(1) In general.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a demonstration project under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] to evaluate the use of bundled payments for the provision of integrated care for a Medicaid beneficiary—“(A) with respect to an episode of care that includes a hospitalization; and “(B) for concurrent physicians services provided during a hospitalization. “(2) Duration.—The demonstration project shall begin on January 1, 2012, and shall end on December 31, 2016. “(b) Requirements.—The demonstration project shall be conducted in accordance with the following:“(1) The demonstration project shall be conducted in up to 8 States, determined by the Secretary based on consideration of the potential to lower costs under the Medicaid program while improving care for Medicaid beneficiaries. A State selected to participate in the demonstration project may target the demonstration project to particular categories of beneficiaries, beneficiaries with particular diagnoses, or particular geographic regions of the State, but the Secretary shall insure [sic] that, as a whole, the demonstration project is, to the greatest extent possible, representative of the demographic and geographic composition of Medicaid beneficiaries nationally. “(2) The demonstration project shall focus on conditions where there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished to Medicaid beneficiaries while reducing total expenditures under the State Medicaid programs selected to participate, as determined by the Secretary. “(3) A State selected to participate in the demonstration project shall specify the 1 or more episodes of care the State proposes to address in the project, the services to be included in the bundled payments, and the rationale for the selection of such episodes of care and services. The Secretary may modify the episodes of care as well as the services to be included in the bundled payments prior to or after approving the project. The Secretary may also vary such factors among the different States participating in the demonstration project. “(4) The Secretary shall ensure that payments made under the demonstration project are adjusted for severity of illness and other characteristics of Medicaid beneficiaries within a category or having a diagnosis targeted as part of the demonstration project. States shall ensure that Medicaid beneficiaries are not liable for any additional cost sharing than if their care had not been subject to payment under the demonstration project. “(5) Hospitals participating in the demonstration project shall have or establish robust discharge planning programs to ensure that Medicaid beneficiaries requiring post-acute care are appropriately placed in, or have ready access to, post-acute care settings. “(6) The Secretary and each State selected to participate in the demonstration project shall ensure that the demonstration project does not result in the Medicaid beneficiaries whose care is subject to payment under the demonstration project being provided with less items and services for which medical assistance is provided under the State Medicaid program than the items and services for which medical assistance would have been provided to such beneficiaries under the State Medicaid program in the absence of the demonstration project. “(c) Waiver of Provisions.—Notwithstanding section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may waive such provisions of titles XIX, XVIII, and XI of that Act [42 U.S.C. 1396 et seq., 1395 et seq., 1301 et seq.] as may be necessary to accomplish the goals of the demonstration, ensure beneficiary access to acute and post-acute care, and maintain quality of care. “(d) Evaluation and Report.—“(1) Data.—Each State selected to participate in the demonstration project under this section shall provide to the Secretary, in such form and manner as the Secretary shall specify, relevant data necessary to monitor outcomes, costs, and quality, and evaluate the rationales for selection of the episodes of care and services specified by States under subsection (b)(3). “(2) Report.—Not later than 1 year after the conclusion of the demonstration project, the Secretary shall submit a report to Congress on the results of the demonstration project.”

Pediatric Accountable Care Organization Demonstration Project

Pub. L. 111–148, title II, § 2706, Mar. 23, 2010, 124 Stat. 325, provided that: “(a) Authority To Conduct Demonstration.—“(1) In general.—The Secretary of Health and Human Services (referred to in this section as the ‘Secretary’) shall establish the Pediatric Accountable Care Organization Demonstration Project to authorize a participating State to allow pediatric medical providers that meet specified requirements to be recognized as an accountable care organization for purposes of receiving incentive payments (as described under subsection (d)), in the same manner as an accountable care organization is recognized and provided with incentive payments under section 1899 of the Social Security Act [42 U.S.C. 1395jjj] (as added by section 3022). “(2) Duration.—The demonstration project shall begin on January 1, 2012, and shall end on December 31, 2016. “(b) Application.—A State that desires to participate in the demonstration project under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. “(c) Requirements.—“(1) Performance guidelines.—The Secretary, in consultation with the States and pediatric providers, shall establish guidelines to ensure that the quality of care delivered to individuals by a provider recognized as an accountable care organization under this section is not less than the quality of care that would have otherwise been provided to such individuals. “(2) Savings requirement.—A participating State, in consultation with the Secretary, shall establish an annual minimal level of savings in expenditures for items and services covered under the Medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] and the CHIP program under title XXI of such Act [42 U.S.C. 1397aa et seq.] that must be reached by an accountable care organization in order for such organization to receive an incentive payment under subsection (d). “(3) Minimum participation period.—A provider desiring to be recognized as an accountable care organization under the demonstration project shall enter into an agreement with the State to participate in the project for not less than a 3-year period. “(d) Incentive Payment.—An accountable care organization that meets the performance guidelines established by the Secretary under subsection (c)(1) and achieves savings greater than the annual minimal savings level established by the State under subsection (c)(2) shall receive an incentive payment for such year equal to a portion (as determined appropriate by the Secretary) of the amount of such excess savings. The Secretary may establish an annual cap on incentive payments for an accountable care organization. “(e) Authorization of Appropriations.—There are authorized to be appropriated such sums as are necessary to carry out this section.”

Medicaid Emergency Psychiatric Demonstration Project

Pub. L. 111–148, title II, § 2707, Mar. 23, 2010, 124 Stat. 326, as amended by Pub. L. 114–97, § 2(a)–(d), Dec. 11, 2015, 129 Stat. 2194–2197, provided that: “(a) Authority To Conduct Demonstration Project.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a demonstration project under which an eligible State (as described in subsection (c)) shall provide payment under the State Medicaid plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] to an institution for mental diseases that is publicly or not publicly owned or operated and that is subject to the requirements of section 1867 of the Social Security Act (42 U.S.C. 1395dd) for the provision of medical assistance available under such plan to individuals who—“(1) have attained age 21, but have not attained age 65; “(2) are eligible for medical assistance under such plan; and “(3) require such medical assistance to stabilize an emergency medical condition. “(b) Stabilization Review.—A State shall specify in its application described in subsection (c)(1) establish [sic] a mechanism for how it will ensure that institutions participating in the demonstration will determine whether or not such individuals have been stabilized (as defined in subsection (h)(5)). This mechanism shall commence before the third day of the inpatient stay. States participating in the demonstration project may manage the provision of services for the stabilization of medical emergency conditions through utilization review, authorization, or management practices, or the application of medical necessity and appropriateness criteria applicable to behavioral health. “(c) Eligible State Defined.—“(1) In general.—Except as otherwise provided in paragraph (4), an eligible State is a State that has made an application and has been selected pursuant to paragraphs (2) and (3). “(2) Application.—A State seeking to participate in the demonstration project under this section shall submit to the Secretary, at such time and in such format as the Secretary requires, an application that includes such information, provisions, and assurances, as the Secretary may require. “(3) Selection.—Except as otherwise provided in paragraph (4), a State shall be determined eligible for the demonstration by the Secretary on a competitive basis among States with applications meeting the requirements of paragraph (1). In selecting State applications for the demonstration project, the Secretary shall seek to achieve an appropriate national balance in the geographic distribution of such projects. “(4) Nationwide availability.—In the event that the Secretary makes a recommendation pursuant to subsection (f)(4) that the demonstration project be expanded on a national basis, any State that has submitted or submits an application pursuant to paragraph (2) shall be deemed to have been selected to be an eligible State to participate in the demonstration project. “(d) Length of Demonstration Project.—“(1) In general.—Except as provided in paragraphs (2) and (3), the demonstration project established under this section shall be conducted for a period of 3 consecutive years. “(2) Temporary extension of participation eligibility for selected states.—“(A) In general.—Subject to subparagraph (B) and paragraph (4), a State selected as an eligible State to participate in the demonstration project on or prior to March 13, 2012, shall, upon the request of the State, be permitted to continue to participate in the demonstration project through September 30, 2016, if—“(i) the Secretary determines that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]; and “(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such extension for that State is projected not to increase net program spending under title XIX of the Social Security Act. “(B) Notice of projections.—The Secretary shall provide each State selected to participate in the demonstration project on or prior to March 13, 2012, with notice of the determination and certification made under subparagraph (A) for the State. “(3) Extension and expansion of demonstration project.—“(A) Additional extension.—Taking into account the recommendations submitted to Congress under subsection (f)(3), the Secretary may permit an eligible State participating in the demonstration project as of the date such recommendations are submitted to continue to participate in the project through December 31, 2019, if, with respect to the State—“(i) the Secretary determines that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]; and “(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act. “(B) Option for expansion to additional states.—Taking into account the recommendations submitted to Congress pursuant to subsection (f)(3), the Secretary may expand the number of eligible States participating in the demonstration project through December 31, 2019, if, with respect to any new eligible State—“(i) the Secretary determines that the participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act; and “(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act. “(C) Notice of projections.—The Secretary shall provide each State participating in the demonstration project as of the date the Secretary submits recommendations to Congress under subsection (f)(3), and any additional State that applies to be added to the demonstration project, with notice of the determination and certification made for the State under subparagraphs (A) and (B), respectively, and the standards used to make such determination and certification—“(i) in the case of a State participating in the demonstration project as of the date the Secretary submits recommendations to Congress under subsection (f)(3), not later than August 31, 2016; and “(ii) in the case of an additional State that applies to be added to the demonstration project, prior to the State making a final election to participate in the project. “(4) Authority to ensure budget neutrality.—The Secretary annually shall review each participating State’s demonstration project expenditures to ensure compliance with the requirements of paragraphs (2)(A)(i), (2)(A)(ii), (3)(A)(i), (3)(A)(ii), (3)(B)(i), and (3)(B)(ii) (as applicable). If the Secretary determines with respect to a State’s participation in the demonstration project that the State’s net program spending under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] has increased as a result of the State’s participation in the project, the Secretary shall treat the demonstration project excess expenditures of the State as an overpayment under title XIX of the Social Security Act. “(e) Funding.—“(1) Appropriation.—“(A) In general.—Out of any funds in the Treasury not otherwise appropriated, there is appropriated to carry out this section, $75,000,000 for fiscal year 2011. “(B) Budget authority.—Subparagraph (A) constitutes budget authority in advance of appropriations Act [sic] and represents the obligation of the Federal Government to provide for the payment of the amounts appropriated under that subparagraph. “(2) availability [sic].—Funds appropriated under paragraph (1) shall remain available for obligation until expended. “(3) Funds allocated to states.—Funds shall be allocated to eligible States on the basis of criteria, including a State’s application (other than States deemed to be eligible States through the application of subsection (c)(4)), as determined by the Secretary. “(4) Payments to states.—The Secretary shall pay to each eligible State (other than a State deemed to be an eligible State through the application of subsection (c)(4)), from its allocation under paragraph (3), an amount each quarter equal to the Federal medical assistance percentage of expenditures in the quarter for medical assistance described in subsection (a). In addition to any payments made to an eligible State under the preceding sentence, the Secretary shall, during any period in effect under paragraph (2) or (3) of subsection (d), or during any period in which a law described in subsection (f)(4)(C) is in effect, pay each eligible State (including any State deemed to be an eligible State through the application of subsection (c)(4)), an amount each quarter equal to the Federal medical assistance percentage of expenditures in the quarter during such period for medical assistance described in subsection (a). Payments made to a State for emergency psychiatric demonstration services under this section during the extension period shall be treated as medical assistance under the State plan for purposes of section 1903(a)(1) of the Social Security Act (42 U.S.C. 1396b(a)(1)). As a condition of receiving payment, a State shall collect and report information, as determined necessary by the Secretary, for the purposes of providing Federal oversight and conducting an evaluation under subsection (f)(1). “(f) Evaluation, Report, and Recommendations to Congress.—“(1) Evaluation.—The Secretary shall conduct an evaluation of the demonstration project in order to determine the impact on the functioning of the health and mental health service system and on individuals enrolled in the Medicaid program and shall include the following:“(A) An assessment of access to inpatient mental health services under the Medicaid program; average lengths of inpatient stays; and emergency room visits. “(B) An assessment of discharge planning by participating hospitals. “(C) An assessment of the impact of the demonstration project on the costs of the full range of mental health services (including inpatient, emergency and ambulatory care). “(D) An analysis of the percentage of consumers with Medicaid coverage who are admitted to inpatient facilities as a result of the demonstration project as compared to those admitted to these same facilities through other means. “(E) A recommendation regarding whether the demonstration project should be continued after December 31, 2013, and expanded on a national basis. “(2) Report.—Not later than December 31, 2013, the Secretary shall submit to Congress and make available to the public a report on the findings of the evaluation under paragraph (1). “(3) Recommendation to congress regarding extension and expansion of project.—Not later than September 30, 2016, the Secretary shall submit to Congress and make available to the public recommendations based on an evaluation of the demonstration project, including the use of appropriate quality measures, regarding—“(A) whether the demonstration project should be continued after September 30, 2016; and “(B) whether the demonstration project should be expanded to additional States. “(4) Recommendation to congress regarding permanent extension and nationwide expansion.—“(A) In general.—Not later than April 1, 2019, the Secretary shall submit to Congress and make available to the public recommendations based on an evaluation of the demonstration project, including the use of appropriate quality measures, regarding—“(i) whether the demonstration project should be permanently continued after December 31, 2019, in 1 or more States; and “(ii) whether the demonstration project should be expanded (including on a nationwide basis). “(B) Requirements.—Any recommendation submitted under subparagraph (A) to permanently continue the project in a State, or to expand the project to 1 or more other States (including on a nationwide basis) shall include a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that permanently continuing the project in a particular State, or expanding the project to a particular State (or all States) is projected not to increase net program spending under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]. “(C) Congressional approval required.—The Secretary shall not permanently continue the demonstration project in any State after December 31, 2019, or expand the demonstration project to any additional State after December 31, 2019, unless Congress enacts a law approving either or both such actions and the law includes provisions that—“(i) ensure that each State’s participation in the project complies with budget neutrality requirements; and “(ii) require the Secretary to treat any expenditures of a State participating in the demonstration project that are [in] excess of the expenditures projected under the budget neutrality standard for the State as an overpayment under title XIX of the Social Security Act. “(5) Funding.—Of the unobligated balances of amounts available in the Centers for Medicare & Medicaid Services Program Management account, $100,000 shall be available to carry out this subsection and shall remain available until expended. “(g) Waiver Authority.—“(1) In general.—The Secretary shall waive the limitation of subdivision (B) following paragraph (28) [now (32)] of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) (relating to limitations on payments for care or services for individuals under 65 years of age who are patients in an institution for mental diseases) for purposes of carrying out the demonstration project under this section. “(2) Limited other waiver authority.—The Secretary may waive other requirements of titles XI and XIX of the Social Security Act [42 U.S.C. 1301 et seq., 1396 et seq.] (including the requirements of sections 1902(a)(1) [42 U.S.C. 1396a(a)(1)] (relating to statewideness) and 1902(1)(10)(B) [probably means 1902(a)(1)(10)(B), 42 U.S.C. 1396a(a)(1)(10)(B)] (relating to comparability)) only to [the] extent necessary to carry out the demonstration project under this section. “(h) Definitions.—In this section:“(1) Emergency medical condition.—The term ‘emergency medical condition’ means, with respect to an individual, an individual who expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others. “(2) Federal medical assistance percentage.—The term ‘Federal medical assistance percentage’ has the meaning given that term with respect to a State under section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)). “(3) Institution for mental diseases.—The term ‘institution for mental diseases’ has the meaning given to that term in section 1905(i) of the Social Security Act (42 U.S.C. 1396d(i)). “(4) Medical assistance.—The term ‘medical assistance’ has the meaning given that term in section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)). “(5) Stabilized.—The term ‘stabilized’ means, with respect to an individual, that the emergency medical condition no longer exists with respect to the individual and the individual is no longer dangerous to self or others. “(6) State.—The term ‘State’ has the meaning given that term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).”

[Pub. L. 114–97, § 2(e), Dec. 11, 2015, 129 Stat. 2198, provided that: “The amendments made by this section [amending section 2707 of Pub. L. 111–148, set out above] shall take effect on the date of the enactment of this Act [Dec. 11, 2015].” ]

Incentives for Prevention of Chronic Diseases in Medicaid

Pub. L. 111–148, title IV, § 4108, Mar. 23, 2010, 124 Stat. 561, provided that: “(a) Initiatives.—“(1) Establishment.—“(A) In general.—The Secretary [of Health and Human Services] shall award grants to States to carry out initiatives to provide incentives to Medicaid beneficiaries who—“(i) successfully participate in a program described in paragraph (3); and “(ii) upon completion of such participation, demonstrate changes in health risk and outcomes, including the adoption and maintenance of healthy behaviors by meeting specific targets (as described in subsection (c)(2)). “(B) Purpose.—The purpose of the initiatives under this section is to test approaches that may encourage behavior modification and determine scalable solutions. “(2) Duration.—“(A) Initiation of program; resources.—The Secretary shall awards grants to States beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. The Secretary shall develop program criteria for initiatives under this section using relevant evidence-based research and resources, including the Guide to Community Preventive Services, the Guide to Clinical Preventive Services, and the National Registry of Evidence-Based Programs and Practices. “(B) Duration of program.—A State awarded a grant to carry out initiatives under this section shall carry out such initiatives within the 5-year period beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. Initiatives under this section shall be carried out by a State for a period of not less than 3 years. “(3) Program described.—“(A) In general.—A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State and approved by the Secretary, that is designed and uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following:“(i) Ceasing use of tobacco products. “(ii) Controlling or reducing their weight. “(iii) Lowering their cholesterol. “(iv) Lowering their blood pressure. “(v) Avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition. “(B) Co-morbidities.—A program under this section may also address co-morbidities (including depression) that are related to any of the conditions described in subparagraph (A). “(C) Waiver authority.—The Secretary may waive the requirements of section 1902(a)(1) (relating to statewideness) of the Social Security Act [42 U.S.C. 1396a(a)(1)] for a State awarded a grant to conduct an initiative under this section and shall ensure that a State makes any program described in subparagraph (A) available and accessible to Medicaid beneficiaries. “(D) Flexibility in implementation.—A State may enter into arrangements with providers participating in Medicaid, community-based organizations, faith-based organizations, public-private partnerships, Indian tribes, or similar entities or organizations to carry out programs described in subparagraph (A). “(4) Application.—Following the development of program criteria by the Secretary, a State may submit an application, in such manner and containing such information as the Secretary may require, that shall include a proposal for programs described in paragraph (3)(A) and a plan to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware and informed about such programs. “(b) Education and Outreach Campaign.—“(1) State awareness.—The Secretary shall conduct an outreach and education campaign to make States aware of the grants under this section. “(2) Provider and beneficiary education.—A State awarded a grant to conduct an initiative under this section shall conduct an outreach and education campaign to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware of the programs described in subsection (a)(3) that are to be carried out by the State under the grant. “(c) Impact.—A State awarded a grant to conduct an initiative under this section shall develop and implement a system to—“(1) track Medicaid beneficiary participation in the program and validate changes in health risk and outcomes with clinical data, including the adoption and maintenance of health behaviors by such beneficiaries; “(2) to the extent practicable, establish standards and health status targets for Medicaid beneficiaries participating in the program and measure the degree to which such standards and targets are met; “(3) evaluate the effectiveness of the program and provide the Secretary with such evaluations; “(4) report to the Secretary on processes that have been developed and lessons learned from the program; and “(5) report on preventive services as part of reporting on quality measures for Medicaid managed care programs. “(d) Evaluations and Reports.—“(1) Independent assessment.—The Secretary shall enter into a contract with an independent entity or organization to conduct an evaluation and assessment of the initiatives carried out by States under this section, for the purpose of determining—“(A) the effect of such initiatives on the use of health care services by Medicaid beneficiaries participating in the program; “(B) the extent to which special populations (including adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program; “(C) the level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and “(D) the administrative costs incurred by State agencies that are responsible for administration of the program. “(2) State reporting.—A State awarded a grant to carry out initiatives under this section shall submit reports to the Secretary, on a semi-annual basis, regarding the programs that are supported by the grant funds. Such report shall include information, as specified by the Secretary, regarding—“(A) the specific uses of the grant funds; “(B) an assessment of program implementation and lessons learned from the programs; “(C) an assessment of quality improvements and clinical outcomes under such programs; and “(D) estimates of cost savings resulting from such programs. “(3) Initial report.—Not later than January 1, 2014, the Secretary shall submit to Congress an initial report on such initiatives based on information provided by States through reports required under paragraph (2). The initial report shall include an interim evaluation of the effectiveness of the initiatives carried out with grants awarded under this section and a recommendation regarding whether funding for expanding or extending the initiatives should be extended beyond January 1, 2016. “(4) Final report.—Not later than July 1, 2016, the Secretary shall submit to Congress a final report on the program that includes the results of the independent assessment required under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. “(e) No Effect on Eligibility for, or Amount of, Medicaid or Other Benefits.—Any incentives provided to a Medicaid beneficiary participating in a program described in subsection (a)(3) shall not be taken into account for purposes of determining the beneficiary’s eligibility for, or amount of, benefits under the Medicaid program or any program funded in whole or in part with Federal funds. “(f) Funding.—Out of any funds in the Treasury not otherwise appropriated, there are appropriated for the 5-year period beginning on January 1, 2011, $100,000,000 to the Secretary to carry out this section. Amounts appropriated under this subsection shall remain available until expended. “(g) Definitions.—In this section:“(1) Medicaid beneficiary.—The term ‘Medicaid beneficiary’ means an individual who is eligible for medical assistance under a State plan or waiver under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) and is enrolled in such plan or waiver. “(2) State.—The term ‘State’ has the meaning given that term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).”

Coordination of Expansion of the Recovery Audit Contractor Program; Regulations

Pub. L. 111–148, title VI, § 6411(a)(2), Mar. 23, 2010, 124 Stat. 775, provided that: “(A) In general.—The Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall coordinate the expansion of the Recovery Audit Contractor program to Medicaid with States, particularly with respect to each State that enters into a contract with a recovery audit contractor for purposes of the State’s Medicaid program prior to December 31, 2010. “(B) Regulations.—The Secretary of Health and Human Services shall promulgate regulations to carry out this subsection [amending this section] and the amendments made by this subsection, including with respect to conditions of Federal financial participation, as specified by the Secretary.”

Annual Report

Pub. L. 111–148, title VI, § 6411(c), Mar. 23, 2010, 124 Stat. 775, provided that: “The Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall submit an annual report to Congress concerning the effectiveness of the Recovery Audit Contractor program under Medicaid and Medicare and shall include [in] such reports recommendations for expanding or improving the program.”

Purposes of 2009 Amendment

Pub. L. 111–5, div. B, title V, § 5000(a), Feb. 17, 2009, 123 Stat. 496, provided that: “The purposes of this title [enacting section 1320b–24 of this title, amending this section and sections 1396o, 1396o–1, 1396p, 1396r–4, 1396r–6, 1396u–2, 1396u–3, and 1397gg of this title, and enacting provisions set out as notes under this section and sections 1396d and 1396r–6 of this title] are as follows: “(1) To provide fiscal relief to States in a period of economic downturn. “(2) To protect and maintain State Medicaid programs during a period of economic downturn, including by helping to avert cuts to provider payment rates and benefits or services, and to prevent constrictions of income eligibility requirements for such programs, but not to promote increases in such requirements.”

Limitation on Waiver Authority

Pub. L. 111–3, title II, § 211(a)(2), Feb. 4, 2009, 123 Stat. 52, provided that: “Notwithstanding any provision of section 1115 of the Social Security Act (42 U.S.C. 1315), or any other provision of law, the Secretary [of Health and Human Services] may not waive the requirements of section 1902(a)(46)(B) of such Act (42 U.S.C. 1396a(a)(46)(B)) with respect to a State.”

Extension of SSI Web-Based Asset Demonstration Project to the Medicaid Program

Pub. L. 110–90, § 4, Sept. 29, 2007, 121 Stat. 985, which required that an automated, secure, web-based asset verification request and response process be applied to Medicaid’s asset eligibility determinations in certain States during a certain period, was repealed by Pub. L. 110–252, title VII, § 7001(d)(4), June 30, 2008, 122 Stat. 2394.

Demonstration Projects Regarding Home and Community-Based Alternatives to Psychiatric Residential Treatment Facilities for Children

Pub. L. 109–171, title VI, § 6063, Feb. 8, 2006, 120 Stat. 99, provided that: “(a) In General.—The Secretary is authorized to conduct, during each of fiscal years 2007 through 2011, demonstration projects (each in the section referred to as a ‘demonstration project’) in accordance with this section under which up to 10 States (as defined for purposes of title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]) are awarded grants, on a competitive basis, to test the effectiveness in improving or maintaining a child’s functional level and cost-effectiveness of providing coverage of home and community-based alternatives to psychiatric residential treatment for children enrolled in the Medicaid program under title XIX of such Act. “(b) Application of Terms and Conditions.—“(1) In general.—Subject to the provisions of this section, for the purposes of the demonstration projects, and only with respect to children enrolled under such demonstration projects, a psychiatric residential treatment facility (as defined in section 483.352 of title 42 of the Code of Federal Regulations) shall be deemed to be a facility specified in section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), and to be included in each reference in such section 1915(c) to hospitals, nursing facilities, and intermediate care facilities for the mentally retarded. “(2) State option to assure continuity of medicaid coverage.—Upon the termination of a demonstration project under this section, the State that conducted the project may elect, only with respect to a child who is enrolled in such project on the termination date, to continue to provide medical assistance for coverage of home and community-based alternatives to psychiatric residential treatment for the child in accordance with section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), as modified through the application of paragraph (1). Expenditures incurred for providing such medical assistance shall be treated as a home and community-based waiver program under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) for purposes of payment under section 1903 of such Act (42 U.S.C. 1396b). “(c) Terms of Demonstration Projects.—“(1) In general.—Except as otherwise provided in this section, a demonstration project shall be subject to the same terms and conditions as apply to a waiver under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), including the waiver of certain requirements under the first sentence of paragraph (3) of such section but not applying the second sentence of such paragraph. “(2) Budget neutrality.—In conducting the demonstration projects under this section, the Secretary shall ensure that the aggregate payments made by the Secretary under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) do not exceed the amount which the Secretary estimates would have been paid under that title if the demonstration projects under this section had not been implemented. “(3) Evaluation.—The application for a demonstration project shall include an assurance to provide for such interim and final evaluations of the demonstration project by independent third parties, and for such interim and final reports to the Secretary, as the Secretary may require. “(d) Payments to States; Limitations to Scope and Funding.—“(1) In general.—Subject to paragraph (2), a demonstration project approved by the Secretary under this section shall be treated as a home and community-based waiver program under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) for purposes of payment under section 1903 of such Act (42 U.S.C. 1396b). “(2) Limitation.—In no case may the amount of payments made by the Secretary under this section for State demonstration projects for a fiscal year exceed the amount available under subsection (f)(2)(A) for such fiscal year. “(e) Secretary’s Evaluation and Report.—The Secretary shall conduct an interim and final evaluation of State demonstration projects under this section and shall report to the President and Congress the conclusions of such evaluations within 12 months of completing such evaluations. “(f) Funding.—“(1) In general.—For the purpose of carrying out this section, there are appropriated, from amounts in the Treasury not otherwise appropriated, for fiscal years 2007 through 2011, a total of $218,000,000, of which—“(A) the amount specified in paragraph (2) shall be available for each of fiscal years 2007 through 2011; and “(B) a total of $1,000,000 shall be available to the Secretary for the evaluations and report under subsection (e). “(2) Fiscal year limit.—“(A) In general.—For purposes of paragraph (1), the amount specified in this paragraph for a fiscal year is the amount specified in subparagraph (B) for the fiscal year plus the difference, if any, between the total amount available under this paragraph for prior fiscal years and the total amount previously expended under paragraph (1)(A) for such prior fiscal years. “(B) Fiscal year amounts.—The amount specified in this subparagraph for—“(i) fiscal year 2007 is $21,000,000; “(ii) fiscal year 2008 is $37,000,000; “(iii) fiscal year 2009 is $49,000,000; “(iv) fiscal year 2010 is $53,000,000; and “(v) fiscal year 2011 is $57,000,000.”

Money Follows the Person Rebalancing Demonstration

Pub. L. 116–260, div. CC, title II, § 204(g), Dec. 27, 2020, 134 Stat. 2983, provided that: “Not later than 1 year after the date of the enactment of this Act [Dec. 27, 2020], the Secretary shall update the terms and conditions of any approved MFP demonstration project under section 6071 of the Deficit Reduction Act of 2005 [Pub. L. 109–171] (42 U.S.C. 1396a note) in effect on the date of the enactment of this Act to ensure that such terms and conditions are the same as are required for any new State applicant for such project under the amendments made by this section.”